某医院临床输血病历质量缺陷分析  

Defects Analysis of Quality of Clinical Transfusion Medical Record in a Hospital

作　　者：孙如鹏[1] 许树根[1] 张庆云[1] 颜裕丰 唐其江 

机构地区：[1]解放军第一七四医院,厦门市361001

出　　处：《中国病案》2014年第1期20-22,共3页Chinese Medical Record

摘　　要：目的加强临床输血病历规范化管理,提高输血病历质量,防范临床用血医患纠纷。方法以临床输血病历的有关规定为依据,采取随机抽查的方法,对我院2012年258份输血病历按季度进行检查统计分析。结果 258份临床输血病历中缺陷病历128份,缺陷率为49.6%,其中用血医嘱不合格病历44份,占17%,临床输血知情同意书不合格病历88份,占34.1%,输血病程记录不合格病历229份,占88.8%。结论需要加强对输血病历的质量管理,有针对地对出现的主要问题制定相应的整改措施,提高病历质量,以降低医疗风险。Objective To strengthen standardized management of clinical blood transfusion medical records, and improve the quality of medical records and prevent medical tangle risk of clinical usage of blood. Methods Based on the standards of blood transfusion medical records writing, a total of 258 medical records in 2012 were examined and the defects were analyzed. Results There were 128 defect transfu- sion medical records in the 258 transfusion medical records, the defects rate was 49.6%. A total of 44 medical records were the doctor＇s ad- vice disqualification, accounting for 17%. A total of 88 medical records were blood transfusion informed consent disqualification, accounting for 34.1%. A total of 229 medical records were blood transfusion progress note disqualification, accounting for 88.80/0. Conclusion A series of countermeasures should be taken to strength the quality control of medical records for clinical blood transfusion management to reduce the risk of blood transfusion medical dispute.

关 键 词：输血病历 质量管理 终末病历 医疗纠纷 

分 类 号：R197.323.1[医药卫生—卫生事业管理]